September 26, 2009

AND: Here's the more distant view of the butterfly (moth?). [Thanks to commenter Seneca: "Butterfly. Moth antennae are fluffy."] And, from the same beautiful herb garden, a hummingbird.

ALSO: Thanks to Instapundit for linking. By the way, when my titles designate a post as a "nightclub," "café," "tavern," "restaurant," or some such place, it means you can use the topic thread to talk about anything you like. It's an open thread, so don't think anybody in there is hijacking the thread or disrespecting my photography.

43 comments:

David Leonhardt on malpractice in Wednesday's NYT business section. Fear of malpractice claims adds 3% to the cost of health care, yet 97% of the time, victims of malpractice just suck it up. From which I infer medicine lacks a culture of continuous process improvement.

- The fear of lawsuits among doctors does seem to lead to a noticeable amount of wasteful treatment: 3% of overall spending, or $60 billion

- At the same time, though, the current system appears to treat actual malpractice too lightly. Far more common than trials are errors that never lead to any action.

- Only 2 to 3 percent of cases of medical negligence lead to a malpractice claim.

For every notorious error — the teenager who died in North Carolina after being given the wrong blood type, the 39-year-old Massachusetts mother killed by a chemotherapy overdose, the newborn twins (children of the actor Dennis Quaid) given too much blood thinner — there are dozens more. You never hear about these other cases.

- Our malpractice system is expensive in all the wrong ways.

- Medical errors happen more frequently here than in other rich countries

- Eeven though the system treats most victims poorly, notes Michelle Mello of the School of Public Health at Harvard, “the uncertainty leads to defensive behavior by physicians that generates more costs for everyone.”

WIRED magazine has an interesting article on Monarch Butterfly GPS in the Sep. online issue.

"Scientists have finally located the 24-hour clock that guides the migration of monarch butterflies. Instead of being in the brain where most people expected, it turns out the circadian clock is located in the butterflies’ antennae."

So, fls, you believe the standard that should be applied to medicine is that every single conceivable error should become a lawsuit? Because doctors should be expected to be 100 percent perfect 100 percent of the time? As determined by a lawyer?

You don't think that maybe a large portion of errors are regrettable but inevitable when humans are involved? Or that lawyers don't have to leap to sue for every single negative thing that ever happens in life?

Maybe 3 percent is about the right percentage of errors that are egregious and truly preventable. Or maybe it's already too high.

Where the real corruption is taking place under Obama are the kind of transactions in which a company funded by a VC firm of a former VP can get a $550M loan from the DOE, for a technology that is admittedly only profitable if the super-rich purchase it.

Did the DOE get enough warrants to protect the taxpayer on the upside, for the risk of such a loan?

Who knows. No so-called news organization of name is reporting the details.

This is all so much of an inside big-money game, and the taxpayer is the sucker.

"From which I infer medicine lacks a culture of continuous process improvement."

BINGO!

Doctors, hospitals and insurance companies know only one way...Expenses, coming through to YOU, patient. Dollar for dollar, plus administrative costs. Add the government in this mix and you get cost plus plus plus, which is best known today as Medicare and Medicaid.

We need PROCESS improvement, starting at the level closest to the patient.

Doctors and hospitals pass along any expenses they incur. It would be the same as any family raising two kids spending "whatever is necessary" because they have grandparents who will ultimately cover the bill. Insurance companies are no more than the accountant/administrators for this ridiculous exchange.

We don't raise our kids "at any cost". We raise our kids the best we can, given the money we have.

Doctors and hospitals need to learn a thing or two about budgeting before we give them the nation's checkbook.

You don't think that maybe a large portion of errors are regrettable but inevitable when humans are involved?

No, because I am no longer living in the 1930s. I think doctors, nurses, pharmacists, et al. should at least be using process improvement techniques common in the 1980s. I suggest FMEA to eliminate the gross errors cited in the article. If the medical establisment adopted six-sigma methods, we could all shout Glory Hallelujah. I would expect malpractice incidents to decline by a factor of 10 to 100.

If I had to single out the biggest problem with the health care process it would be lack of communication among all the players.

Or that lawyers don't have to leap to sue for every single negative thing that ever happens in life?

Given that they take home a paycheck only when they win, and given the cost of demonstrating malpractice, lawyers tend to bring suit only for the slam-dunk cases.

Further, fear of lawsuits has accomplished little if the additional overhead intended to prevent lawsuits has not eliminated even the gross errors.

The jokes about Althouse having to circle her toe with magic marker would be funny if they weren't true.

From which I infer medicine lacks a culture of continuous process improvementPerhaps there's too much CYA, so they do things strictly by the book. Now, at least, they don't throw away the blood they extract from you.

We need PROCESS improvement, starting at the level closest to the patient.

Penny, I read that as directed to nursing professionals. My wife is an RN, involved with end-of-life patients. In her view, the problem is unrealistic expectations on the part of the patients and families. When faced with decisions affecting loved ones, far too many people lack a cost/benefit understanding of the many possibilities, often choosing more life at any cost. Who is a healthcare professional to deny the wishes of a patient?

Just a few days ago, I remarked that in Europe (that paradigm of healthcare which so many in the current administration aspire to), births and deaths tend to occur more frequently at home. Her response (she is geared to analyze staffing costs and patient load situations) was: that would cut costs by 30%. I don't know where she pulled that number from, but it seems low to me.

So before you rail against hospital staff as being frozen in some sort of "process improvement" limbo, you should consider whether you (or anyone you know) isn't also stuck in a mood of thinking which is unrealistic. Just my $0.02. :)

No need to worry about what you can afford as a parent. We are only focusing on you being the "best" parent.

Well, that is how hospitals and doctors and medical laboratories conduct their business. Money? Not an object. We save lives.

While they are of the same heart as you, their checking account has no limit. They are never overdrawn. And what they spend is passed along...to you, and me, and many others by way of insurance companies.

Hey! Let's blame the insurance companies! They don't seem to have a "higher calling".

I'm surprised no one has objected to the two unfounded assertions thrown out by FLS and Penny - that there is no quality improvement process in the medical field, and that all costs are passed along.The pharmaceutical industry is a huge QA player. Try Googling ICH and check their annual QA initiatives. Doctors, being generally smaller businesses, don't have a formal program along the lines of a Six Sigma plan. They are expected to keep informed through business contacts and journal articles (kinda like with lawyers, eh?). This adds inefficiencies, to be sure - but the trade off is non-monolithic care, a huge plus for the development of medical practices.As far as the costs are concerned, most medical industry players are at the mercy of reimbursement rates. Your doctor must accept the copay rate if he takes your insurance,and costs are high enough that most consumers are forced to stay in-network to afford care. The doctor or pharmacy can't pass on costs-they are going to get the predefined payment plus the copay for any treatment or drug. That's why a pharmacy will have tons of other items for sale which are not price-fixed. Wal-Mart is heavily pushing its' pharmacy, not because the profit is so great, but because you might buy a Coke while you are in the store-and the profit is significant there.Long post, but the premise of lack of QA and total cost pass-thru are dead wrong, and it took a bit to address it.

Logic FLS style: the fact that many who experience medical errors don't sue for malpractice necessarily leads to the inference that medicine lacks a culture of continuous error improvement. Oh I see. Wait. I'm sorry. What??

Logic Penny style: errors happen in medicine. I know why! It's because every doctor and nurse in America is motivated by greed!

Both Penny and FLS imagine that they are so much smarter than a nation full of doctors, nurses and medical administrators that they are the first to suggest the use of error avoidance protocols. What planet do you two live on? Every medical practice in this country is already up to its ears in pre-error avoidance protocols and in post-error systems analysis, everywhere. Every time any nurse hands you a medication you may be certain that the action was preceded by dozens of steps specifically designed to try to make certain he is handing you the right one. Every time a pharmacist fills your prescription, same thing. Every time a doctor writes down a diagnosis, same thing. Every time a hospital buys a piece of medical equipment or lays out a treatment protocol, same thing. And once errors have been made, Earth to FLS: a lawsuit is not the only means by which doctors, nurses and hospital administrators can figure out what went wrong, make certain it does not happen again, and try to make things right for the person who suffered the error.

Can error-avoidance procedures be improved? Of course, and they are being improved every day. Will they ever result in complete freedom from medical errors? Of course not. We are dealing with human beings. Perhaps FLS and Penny can say honestly that they get through a typical work week without making a single error, large or small but if so, I'm thinking it's because they have appropriately unchallenging jobs.

If self-righteous smug ignorance could save the world, we'd be all set with FLS and Penny.

I had surgery on my right shoulder in 2000, not long after that guy had the wrong foot amputated.

The nurse came into the room before my pre-op stuff and asked what I was having done. I thought, "don't you know?" but I told her. (Of course she knew, she had my chart.)

"Which shoulder?"

"Right."

"Show me."

I pointed.

She took hold of it.

"This?"

"Yes."

She wrote YES on that arm with a sharpie, and NO on the other.

The most basic quality system requires some imagination. You have to be able to ask, exactly what could go wrong, and exactly how can we prevent that from ever happening. Sometimes these things will be reactions to something that has happened, possibly elsewhere as in the wrong foot amputation, and sometimes they will be the result of near misses or just somebody's alertness.

Then you work out a procedure for preventing screwups. Then - the hardest part - you follow your procedure consistently.

Six sigma and other programs are an attempt to formalize this but you have to have common sense and you have to apply it, and if you have and do those things that's actually probably adequate. So you can have major hospital systems with major quality breakdowns, and small one-doctor practices with no human error screwups. And that's just how it is.

Given that they take home a paycheck only when they win, and given the cost of demonstrating malpractice, lawyers tend to bring suit only for the slam-dunk cases.

Nice theory.

Bullshit reality.

2 of my brothers are physicians, as are a brother-in-law, an uncle (as was his father before him)a niece and 3 first cousins.

There are 7 attorneys on my wife's side of the family and 2 on mine and 6 of those are litigators.

And one of my wife's college roommates is an assistant prof currently doing her doctoral thesis on mid-range (less than $500,000) malpractice suits and their results.

They all agree that the system does not favor doctors in malpractice once a suit has begun, regardless of it's merit. And that alone is an encouragement to file far more than should ever see the light of day.

I paid Medicare taxes since they were instituted in 1966. Now I reach retirement age and become eligible for my prepaid coverage, but our excretable govt decides to limit the service. You would go to jail in the private sector if you stiffed your customers as the govt is planning to do.

Medical errors happen more frequently here than in other rich countries

Medical errors are detected and reported more commonly here. In other countries, the doctors are government bureaucrats and therefore most probably corrupt and dishonest, and any but the most obvious mistakes are buried.

Medicine is not a series of separate silos, but a group that should be acting as a team. The QA at pharmaceutical companies does little good to a patient whose nurse has given him the wrong pills.

From a 2001 report of 1500 "Adverse Drug Events":

Faulty prescribing was the most common reason for medication error, and wrong dosage was the most common type of error. Overall, 52% of the cases were judged to have been preventable; of these, 50% could have been prevented by a pharmacist. Litigation was reported for 13% of the cases; settlements and judgments averaged $3.1 million.

That half of these events were preventable suggests a lot of low-hanging fruit to be picked. Neither the "accidents happen" nor the "we have QA" points of view are terribly helpful when problems exist to be eliminated.

Should I wait to remind him of this until Tel Aviv or New York is a pile of cinders, or may I rub his nose in it when they do their first test explosion?

These would show that the goal of eliminating Iran's nuclear threat had not been met.

An example of "Victory" was when Chamberlain declared "Peace for our time," after Britain, France, and Italy let Hitler take over the Sudetenland -- he really only wanted one thing, right?

Any Iranian nuclear attack on Tel Aviv would be returned in kind, so I doubt Iran would try anything there. For lack of other delivery systems, Iran would have to ship any nuclear weapon to New York in a shipping container -- hopefully we could detect it before the ship arrives.

The perfect example of actual process improvement in medicine is the development of electronic medical records (EMR) and electronic prescribing. Scripts are sent directly to the pharmacy, eliminating errors due to sloppy handwriting. All the e-prescribe systems have alerts that look at what you've just prescribed and the medications the patient is already taking for possible interactions, duplications, etc. The EMRs have been developed without government diktat and some (including the one we use) were created by doctors themselves. Anyone who is involved in direct patient care worries about injury or harm to his/her patients and we certainly try to avoid errors (being human, this is not always possible). To imply that hospitals and providers have no interest in making our patients safer is absolute nonsense.